ATTACHMENT 2
Personal Net Worth Statement
Revised 1/15/10
City of Chicago and Illinois Unified Certification Programs
As of (insert date):
For DBE certification, each owner claiming to be socially and economically disadvantaged must complete the form.
For M/WBE and BEPD certification, each qualifying owner of the Applicant firm must complete the form and all non-qualifying
owners who possess 20% or more interest in the Applicant firm are required to complete the form.
Business Name
Owner Name
Business Phone
Residence Address
Residence Phone
City, State & Zip Code
Email
ASSETS
LIABILITIES
(only $, not ¢)
(only $, not ¢)
Cash on hand & in Banks
$
Accounts Payable
$
Savings Account
$
Notes Payable to Banks and Others
$
(Describe in Section 2)
IRA or Other Retirement Account
$
Installment Account (Auto)
$
Accounts & Notes Receivable
$
Monthly Payments
Life Insurance - Cash Surrender Value
$
Installment Account (Other)
$
Monthly Payments
$
Loan on Life Insurance
$
$
Mortgages on Real Estate
$
$
$
(Describe in Section 8)
Stocks and Bonds
$
(Describe in Section 3)
Real Estate
(Describe in Section 4)
Automobile-Present Value
(Describe in Section 4)
Other Personal Property
$
Other Assets
(Describe in Section 5)
$
Unpaid Taxes
(Describe in Section 6)
(Describe in Section 5)
$
$
Other Liabilities
(Describe in Section 7)
$
Total Liabilities
$
Net Worth
(Assets - Liabilities = Net Worth)
Total Assets
Section 1. Source of Income
$
Contingent Liabilities
Salary
$
As Endorser or Co-Maker
$
Net Investment Income
$
Legal Claims & Judgments
$
Real Estate Income
$
Provisions for Federal Income Tax
$
Other Income (Describe below)*
$
Other Special Debt
$
Description of Other Income in Section 1.
* Alimony or child support payments need not be disclosed in "Other Income" unless it is desired to have such payments counted towards total income.
Section 2. Notes Payable to Banks and Others (Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)
Name and Address of Note holder(s)
Original
Balance
Current
Balance
Payment
Amount
Frequency How Secured or Endorsed Type
(monthly, etc.)
of Collateral
Section 3. Stocks and Bonds (Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)
Number of
Shares
Name of Securities
Market Value
Quotations/Exchange
Cost
Date of Quotation/Exchange
Total Value
Section 4. Real Estate Owned (List each parcel separately. Use attachment if necessary. Each attachment must be identified as part of this statement and signed.)
Property A
Property B
Property C
Type of Property
Address
Date purchased
Original Cost
Present Market Value
Name & Address of Mortgage Holder
Mortgage Account Number
Mortgage Balance
Amount of Payment per Month/Year
Status of Mortgage
Section 5. Other Personal Property and Other Assets
Section 6.
Unpaid Taxes
Section 7. Other Liabilities
Section 8. Life Insurance Held
(Describe, and if any is pledges as security, state name and address of lien holder, amount of
lien, terms of payment and if delinquent, describe delinquency)
(Describe in detail, as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches.)
(Describe in detail.)
(Give face amount and cash surrender value of policies - name of insurance company and beneficiaries.)
I authorize the City of Chicago to make inquiries as necessary to verify the accuracy of the statements made. I certify the above and the
statements contained in the attachments are true and accurate as of the stated date(s). These statements are made for the purpose of
verifying economic disadvantage or obtaining certification as a Disadvantaged Enterprise (49 CFR Parts 26 and 23) and/or Minority or
Women-Owned Business Enterprise and/or Business Enterprise owned by People with Disabilities (Chicago Municipal Code 2-92). I
understand FALSE statements may result in possible prosecution by the U.S. Attorney General (Reference 18 U.S.C. 1001) and/or the
applicable local authority (740 ILCS 175/3, Chicago Municipal Code 1-22).
Signature:
Date:
SSN:
Signature:
Date:
SSN: